Triage Nurses: what are your favorite phrases to document?

[nerdgrl]

I start triaging patients in the waiting room soon and I'd love to make myself a quick reference list of phrases to use to document pt condition quickly/succinctly. Some common phrases I've seen from my co-workers include: "No apparent distress," "Pink, warm, dry," "Using cell phone," "ambulated to desk."

[TuxnadoDO]

I really much prefer if the triage nurse documents the patients complaint, general appearance (e.g. no distress) and any very relevant history they bring up. For instance, they are here because they have arm pain, and it's in a splint that was applied one week ago when they were diagnosed with a fracture. Or the patient has abdominal pain, and has a history of bariatric surgery.

Never forget that your words have power, and you can introduce bias in the mind of the physician when he or she reads it. You may be trying to be helpful in offering more information, but you can send someone down the wrong road as well, if you are pointing at a specific diagnosis that hasn't been made or implying the patient is fine.

During residency, a woman in her early 40s checked in for abd pain and leg pain, she was documented to be eating a box of donut holes in triage and assigned to the APP-run section of the ED. She got up from her room, walked to the bathroom, on the way back she collapsed in cardiac arrest. After 90 minutes resus she could not be revived. One of the reasons I do not believe in positive Cheeto sign.

[JKL33]

I like having your input on AN, TuxnadoDO.

Your post had me thinking about this for a bit tonight.

I really much prefer if the triage nurse documents the patients complaint, general appearance (e.g. no distress) and any very relevant history they bring up. For instance, they are here because they have arm pain, and it's in a splint that was applied one week ago when they were diagnosed with a fracture. Or the patient has abdominal pain, and has a history of bariatric surgery.

I can understand why this is what seems acceptable for your needs...but hear me out - I'd like to explain why it might not serve the patients' needs, because it might not be what I need in order to make the right decisions.

I trust (sincerely) that you get what the role of the triage nurse is. But you might be associating that role mostly with the end result it produces (getting a patient to a room for you to examine) rather than the steps that I need to take to get the right patients in the right places on the right timeline.

For example - the splinted/casted patient with arm pain s/p fracture. In a different world I might be able to write "left arm pain s/p fx 1 wk. ago. Splint intact" and sent the patient right to the room where a physician was ready and waiting to take in all the important information. But that isn't reality. If it were, triage wouldn't need to exist. Reality is that the beds are full and the chairs are, too, half the time. So then how do we decide if the patient needs the bed or chair right this instant? If this is ESI 2/compartment syndrome/rotting flesh under splint or ESI 5/"need more norco"/need re-check or something in-between? By getting more info.

Ultimately, your duty is not affected if this patient happens to be in no acute distress, has normal circulation to the extremity and also happens to tell me that s/he stopped by the ED because they haven't been able to get that ortho f/u appointment scheduled yet. But the triage role is affected by that information - because the triage role is to put all of the waiting patients in some kind of order of acuity.

Never forget that your words have power, and you can introduce bias in the mind of the physician when he or she reads it. You may be trying to be helpful in offering more information, but you can send someone down the wrong road as well, if you are pointing at a specific diagnosis that hasn't been made or implying the patient is fine.

The topic of physician bias secondary to triage note is a topic that gets discussed in the workplace from time to time, usually through informal conversation. Respectfully: For various reasons, this is a non-starter. It can't be an issue. I have heard many a physician talking with APPs to that very effect. I have to try to make a judgment based upon my history/assessment findings. The physician must do the same, based upon their own history/assessment. The fact that half the time the patient tells the physician something a good deal different than what they told the triage nurse should be enough of a reason to view triage information as just one of many pieces of data.

During residency, a woman in her early 40s checked in for abd pain and leg pain, she was documented to be eating a box of donut holes in triage and assigned to the APP-run section of the ED. She got up from her room, walked to the bathroom, on the way back she collapsed in cardiac arrest. After 90 minutes resus she could not be revived. One of the reasons I do not believe in positive Cheeto sign.

I get that these things happen. They happen sometimes even when no patient has been disregarded and has, in fact, received competent care. The retrospectoscope sometimes just isn't kind to either of our camps. In fact, the main reason not to write "eating cheetos" is so that, when random-but-inevitable badness happens, it doesn't somehow become the writer's fault.

The donut comment may have been written from a place of disregard. If so, the problem is that the patient was disregarded or that the information was used inappropriately/given too much weight; not that it was categorically wrong to have noted the patient's presence/absence of appetite or ability to eat/not vomit/not refusing food.

I know this is getting lengthy, but there's one more thing. Our documentation does have to support our decision-making, similar to the way that works for the physicians. I might not write "eating cheetos," but all those times that I don't make the 20/10 pain an ESI 1 or 2 something has to convey that my decision was appropriate. I can't just write "20/10 back pain. NKI. NAD" and assign an ESI 4 and put them back out in the waiting room. If only life were that simple. It "feels better" to add in "ambulates with brisk gait" or "denies recent illness or other complaint" or "reports out of norco" or...I don't know...some piece of (factual) information that helps explain the decision-making.

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TL/DR: Sometimes we can't be quite as brief/simple as suggested since triage is a sorting/decision-making process. We 1) need enough info to make the right decision and 2) need to document in a way that explains/supports the decision-making.

[TheSquire, DNP, APRN, NP]

I get that these things happen. They happen sometimes even when no patient has been disregarded and has, in fact, received competent care. The retrospectoscope sometimes just isn't kind to either of our camps. In fact, the main reason not to write "eating cheetos" is so that, when random-but-inevitable badness happens, it doesn't somehow become the writer's fault.

The donut comment may have been written from a place of disregard. If so, the problem is that the patient was disregarded or that the information was used inappropriately/given too much weight; not that it was categorically wrong to have noted the patient's presence/absence of appetite or ability to eat/not vomit/not refusing food.

To back this up - "cheeto sign" or variants thereof is used to minimize a patient's report of "not being able to keep food down" or other apparently dramatic GI complaint. It doesn't mean "the patient's fine," it means "whatever problem this patient may have, it's not prima facie a GI one." Any prudent clinician should know that older women presenting with abd pain still need a cardiac workup...which the "cheeto sign" doesn't negate. As such, the physician's story of an older female patient "eating donuts" in triage after c/o abd pain having a subsequent fatal cardiac event, while unfortunate, doesn't diminish the usefulness of such documentation.

[EDtom]

10/10 cotton mouth 30min after smoking marijuana